BREAST CA MANAGEMENT

ILA NANGGAI
 ANATOMY OF BREAST
• Breast is a modified sweat gland, located between
subcutaneous fat and the fascia of the pectoralis
muscle and serratus anterior muscle
• Extends from lateral sternal border to the mid-axillary
line, from the 2nd to 6th rib
• Axillary tail of Spence pierces the deep fascia and
enters the axilla
• Contains 15-20 lobules of glandular tissues that drains
into a lactiferous duct which converges towards the
nipple, lobules separated by fibrous septa running from
the subcutaneous tissue to the fascia of the chest wall
• The areola is lubricated by the glands of Montgomery
 ANATOMY OF BREAST
Arterial supply
• Internal thoracic artery - via perforating branches
• Axillary artery - 2nd division long thoracic,
thoracoacromial branches
• Subcapsular artery - thoracodorsal branch
• 2nd to 5th intercostal arteries

Venous drainage
• Internal thoracic vein
• Axillary vein
• Lateral thoracic vein
• Intercostal veins
 ANATOMY OF BREAST
Lymphatic drainage
• Axillary nodes - about 85% - drains
into supraclavicular and jugular
nodes
– Lateral, along the axillary vein
– Anterior, along the lateral thoracic vessels
– Posterior, along the subcapsular vessels
– Central, embedded in fat in the centre of the axilla
– Interpectoral, a few nodes lying between the
pectoralis major and minor muscles
– Apical, which lie above the level of the pectoralis
minor tendon

• Internal mammary nodes - about

15%
CLASSIFICATION OF BREAST TUMOUR
 RISK FACTORS
Non-modifiable Modifiable
 Increasing age  Nulliparity
 Female sex  Lack of breastfeeding
 Family history of breast cancer  Older age at first livebirth
 BRCAI, BRCAII  Oral contraceptives
 Early menarche  Hormone replacement therapy
 Late menopause  Unopposed estrogen use in hysterectomised
 History of breast neoplasm women
 Increased mammographic density  Obesity
 Low physical activity
 Radiation exposure
 Alcohol intake
 Smoking
 PROTECTIVE FACTORS
• Exercise
• Early pregnancy
• Breastfeeding
• Limit alcohol
• No smoking
• Weight control
• Limit HRT
• Selective Estrogen Receptor Modulators (SERMs) - Tamoxifen, Raloxifene
• Aromatase Inhibitors - Letrozole, Anastrozole
• Risk reducing mastectomy
• Risk reducing oopherectomy
TRIPLE ASSESSMENT
 HISTORY TAKING

Patient presenting with breast lump :

• When and how was the lump noticed - site, incidental/self-examination, previous trauma
• How has the lump changed - duration, increase in size, changes in nipple, overlying skin
changes, asymmetry of breast, swelling
• Other sx - pain, nipple discharge (if present - colour, consistency)
• Single or multiple, in relation to menstrual cycle or previous pregnancy
• Assessment of malignancy risk - early menarche, late menopause, late age at first
livebirth, nulliparity, HRT, OCP, family history, previous breast disease, radiation
exposure, alcohol intake, smoking
• Protective factors - breastfeeding, physical activity, SERMS
• Systemic review - LOA, LOW, fever, SOB, bone pain, jaundice
 PHYSICAL EXAMINATION
Preliminaries - introduction, chaperone, adequate Palpation
exposure, good lighting, position  Lump - site, size, shape, warmth, tenderness,
Inspection surface, margins, consistency, fluctuance, fixation,
• General appearance - cachexic, jaundiced, mobility
pallor, tachypneic  Ask patient to express the nipple discharge

• Asymmetry of breasts, any lumps, any scars of  Lymph nodes - site, size, consistency, mobility
previous operation or procedure
• Overlying skin changes - fixation of lump to
To complete
skin, Peau d’orange, ulcerating fungating lump,
 Examine supraclavicular LN & cervical LN
retraction of skin, erythema
• Nipple changes - discharge, deviation,  Lungs for pleural effusion
retraction, puckering, discolouration, dermatitis  Percuss spine for bony tenderness
• Ask patient to raise arms- dimpling  Abdomen for hepatomegaly
• Ask patient to contract pectoralis major
 IMAGING
Mammography
• Usually performed in asymptomatic older
women
• Malignant findings : New or spiculated mass,
clustered micro-calcifications in linear or
branching array, architecture distortion
• Benign findings : Radial scar, fat necrosis
 IMAGING
Ultrasonography
• Usually 1st investigation in young patients (<35 y/o),
pregnant, lactating
• Malignant features : borders speculation,
microlobulation, angular margins, internal calcification,
taller than wide (fir-tree appearance; invasion of fascia),
central vascularity, hypoechoic nodule/posterior acoustic
shadowing
• Benign features : smooth margins, well-circumscribed,
thin echogenic capsule, ellipsoid shape,
macrolobulations, hyperechogenicity
 IMAGING
Magnetic Resonance Imaging (MRI)
• Good soft tissue definition without
radiation
• Indications : Occult lesions (axillary
lymphadenopathy but mammogram
and USG negative), determine extent
of disease, suspicion of multicentric
or bilateral malignancy, assessment
of response to neoadjuvant
chemotherapy, when planning for
conservation surgery, screening
 STAGING INVESTIGATIONS
• Chest Xray - lung metastases
• LFT - raised ALP
• CT TAP - metastases to lung, liver,
adrenal gland, ovary
• Bone scan
• PET scan
• CT or MRI Brain - in case of
altered mental status
 MINIMALLY INVASIVE BIOPSY TECHNIQUE (MIBT)
Fine needle aspiration cytology
• Least invasive, very accurate, but only cells are
obtained
• Cannot differentiate between in-situ cancer and
invasive cancer

Core biopsy (Trucut)

• Better diagnostic value
• Can stain for ER/PR status
• Can obtain tissue specimen, so able to differentiate
between invasive and non-invasive disease

• Both procedures can be guided via clinical

palpation or radiological guided (if the mass is small
or difficult to palpate)
BIRADS CLASSIFICATION
 TNM CLASSIFICATION
 TX / TO / Tis • N1: Metastasis in movable, ipsilateral
 T1: Tumor 2 cm or less Level I & II nodes
• N2: Metastasis in Ipsilateral Level I & II
 T2: Tumor >2 but not > 5cm nodes fixed to one another (matted) or in
 T3: Tumor > 5cm Ipsilateral IM nodes in the absence of
axillary nodes
 T4: Tumor of any size with
• N3: Metastasis in Level III nodes, or
extension to chest wall and / or to Ipsilateral Supraclavicular nodes or
the skin (“Peau d Orange” / Ipsilateral IM Nodes + Axillary Nodes
Ulceration / Nodule) or
Inflammatory Carcinoma (Erythema
& Peau d Orange involving approx. a • MO: No Metastasis
third or more of the skin over the • M1: Metastases +
breast)
 STAGING
• Early breast Ca - Stage I and II
• Locally advanced breast Ca - Stage III
• Metastatic breast Ca - Stage IV
 SURGERY
• Breast Conserving Surgery (Wide Excision)
– Removal of tumour with clear margins, while achieving good cosmetic result
– Criteria :
• <=T2 : Tumour <5cm, no skin or chest wall involvement
• Only 1 tumour, not multicentric/multiple DCIS/LCIS unless same quadrant
• No metastatic disease
• Appropriate tumour size-to-breast ratio
• Patient must agree to post-operative radiotherapy
– Higher risk of recurrence in younger patients as cancer tends to be more
aggressive
• Mastectomy
– Removal of breast tissue, nipple-areolar complex, and overlying skin
– Lower rates of local recurrence; similar long term prognosis as wide excision
 SURGERY
• Axillary clearance
– Sentinel lymph node (SLN) biopsy is the standard of care
– Performed for all invasive carcinoma
– A positive sentinel lymph node is associated with further axillary disease, earlier
disease recurrence and poorer overall survival rate
– If the SLN is positive for metastasis, a standard completion of axillary clearance is
the current recommendation :
• Removal of level I and level II nodes and if grossly involved then level III nodes
• Should remove >10 nodes
• Patients with >4 positive axillary LN should undergo adjuvant radiation to the regional LN
• Palliative surgery
– Palliative mastectomy for symptoms - bleeding, fungating, infected tumour
– Surgery at other sites - fixation of pathological fractures, decompression of spinal
cord compression, surgical excision of brain metastases
COMPLICATIONS OF MASTECTOMY AND AXILLARY
CLEARANCE
Immediate • Injury to axillary vessels
• Neuropathy secondary to injury to motor nerves of the axilla
Early • Hemorrhage/Hematoma (POD1)
• Wound infection (POD3)
• Seroma
• Flap ischemia
• Pain and numbness in the upper arm and axilla
• Restricted shoulder mobility
Late • Cosmetic deformity
• Lymphedema
• Lymphangiosarcoma
 CHEMOTHERAPY
• Neoadjuvant
– Given in Stage III to shrink the tumour before surgical resection
– Need to place a clip into the tumour before starting neoadjuvant therapy to guide
surgery in case the tumour “disappears”, operate according to pre-op staging
• Adjuvant
– Typical regime : 6-8 cycles of FEC (5-Fluorouracil, Epirubicin, Cyclophosphamide)
– Start 3/52 after surgery
– Premenopausal patients tend to have better response to chemotherapy than
hormonal therapy
• Palliative
– Anthracyclines and taxanes are the mainstay
– Helps to reduce load of disease to alleviate symptoms, increase survival
 RADIOTHERAPY
• Adjuvant
– External beam whole breast radiotherapy to be done for most patients treated with
breast conserving therapy
– For patients who undergo mastectomy for locally advanced breast cancer
– Patients with >4 pathologically involved nodes should undergo radiotherapy to
regional LN
– Regime consists of 25 to 30 cycles in total, 1 cycle per day for 5 days over 5-6/52 until
maximum dose

• Palliative

• Side effects:
– Short term : skin irritation, tiredness, breast swelling, cough
– Long term : skin pigmentation, rib fracture, angiosarcoma, RT induced cancer
– Radiation to axilla : lymphedema, axillary fibrosis
 HORMONAL THERAPY
• Used in adjuvant setting to eradicate micrometastases
• For ER/PR positive
• Preferred for postmenopausal women
• Reduces risk in contralateral breast

Classes :
• Selective estrogen receptor modulators (SERMs) : Tamoxifen
– Daily for 5 years then stop
– Side effects : Tamoxifen flare - menopausal sx (hot flushes, sweating, fatigue),
Endometrial cancer, DVT
• Aromatase inhibitors : Lanastrazole, Letrozole
– Inhibits peripheral conversion of testosterone and androstenedione to estradiol
– Only suitable for post-menopausal patients
– Side effects : MSK pain, Osteoporosis
 HORMONAL THERAPY
• Targeted therapy : Herceptin (Trastuzumab)
– Administered IV monthly for 12 months
– Targets HER-2 receptor
– Side effects : Cardiomyopathy & CCF (need ECHO), Pulmonary
toxicity, Febrile neutropenia

• Post-menopausal : Aromatase inhibitors for 5 years or

Tamoxifen for 5 years
• Pre-menopausal : Tamoxifen for 5 years KIV ovarian
ablation for high risk patients
 OVARIAN SUPPRESSION/ ABLATION
• For pre-menopausal women, ovarian function can be
permanently suppressed by ovarian ablation, accomplished by
surgical oophorectomy or ovarian irradiation
• Ovarian suppression induces temporary amenorrhea by
utilizing luteinizing hormone-releasing hormone agonists
(Goserelin, Leuprorelin) - results in suppression of luteinizing
hormone and release of follicle stimulating hormone from the
pituitary leading to reduced ovarian estrogen production
 LOCAL TREATMENT
Bone
• Skeletal-related events such as bone pain, pathological fractures, cord
compression and hypercalcemia
• To prevent or delay Radiotherapy (gives adequate pain control even without
analgesics), Endocrine treatment, Bisphosphonates, Surgical stabilization or
decompression for long bone fracture and symptomatic spinal metastases
Liver
• Liver resection and local ablation (radiofrequency, thermal and cryo-ablation)
Lungs
• Radiotherapy
Brain
• Surgery followed by brain radiotherapy
LOCO-REGIONAL RECURRENCE
 FOLLOW UP
• Regular follow-up visits are recommended :
– every 3 - 4 months in the first two years
– every 6 - 8 months from subsequent years
– 3 - 5 and annually thereafter

• The interval of visits should be adapted to the risk of

relapse and patients’ needs.
• The recommended surveillance are :
– annual ipsilateral (after BCS) and/or a contralateral mammography (after mastectomy),
with US and breast MRI when needed
– regular bone density evaluation for patients on AIs or undergoing ovarian function
suppression
– encouragement towards adopting a healthy lifestyle, including diet modification and
exercise
SCREENING
 SUPPORTIVE TREATMENT
• Psychosocial assessment and intervention - fear of recurrence, body
image disruption, feelings of vulnerability, marital/partner
communication
• Physiotherapy - to prevent contractures and muscle wasting
• Breast care nurse - improves continuity of care
• Lifestyle modification - healthy weight, regular physical activity, dietary
modification, limiting alcohol intake, smoking cessation
• Palliative care - incorporates psychosocial and spiritual care
• Breast cancer patient support groups - Pink Unity, Breast Cancer
Foundation
 REFERENCES
• CPG Management of Breast Cancer Third Edition, 2019
• Bailey & Love’s Short Practice of Surgery, 27th Edition
• AJCC Cancer Staging Manual, 8TH Edition , New York, Springer
2018